Thoracic Aortic Aneurysm and Dissection

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Presentation :

Symptomatic aortic aneurysms may present with compressive symptoms such as hoarseness, dysphagia, recurrent pneumonia, and SVC syndrome.

Surveillance intervals for asymptomatic thoracic aortic aneurysm of the aortic root and ascending aorta are:
- 3.5 to 4.4 cm → annual imaging
- 4.5 to 5.4 cm → every 6 months

Medication to lower BP to <130/80 mm Hg:
- β-blockers are the preferred antihypertensive agent
- In patients with Marfan syndrome, β-blockers and losartan reduce the rate of aneurysm growth
Surgery is recommended when any of the following is present:
- aortic diameter >5.5 cm (4.0-5.0 cm for Marfan syndrome and other hereditary disorders)
- aortic diameter >4.5-5.0 cm and undergoing other heart surgery
- rapid growth >0.5 cm/year or ≥0.3 cm/year over 2 years
Emergent surgery for:
- cardiogenic shock
- type A dissection
- type A intramural hematoma
Uncomplicated type B dissection is treated with continued medical therapy alone, except in patients with complications, including end-organ ischemia.
For acute dissection:
- SBP to <120 mm Hg in first hour
- IV β-blocker therapy ± nitroprusside
- pain control with opioids
AVOID:
- Hydralazine for acute aortic dissection because it increases shear stress 2/2 reflex tachycardia